Occurrence Of Recurrent Stroke Research Articles

Red blood cell distribution width in different time-points of peripheral thrombolysis period in acute ischemic stroke is associated with prognosis.

The relationship between red blood cell distribution width (RDW) in peripheral thrombolysis period and prognosis is not fully clarified in those who underwent intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). Our study aimed to clarify this issue. A retrospective analysis of about 510 consecutive thrombolysis cases for AIS from January 2015 to March 2019 in a single-center database was done and followed-up for 3 months. We used univariate and multivariable models to evaluate the relationship between RDW levels at various time-points after IVT and the occurrence risk of hemorrhagic transformation (HT) and recurrent stroke, and used COX regression to assess the hazard ratios of outcomes with RDW levels. Elevated risk of HT was found in higher tertiles of RDW (OR = 10.282, 95% confidence interval (CI) 2.841–39.209, P < 0.001 in Tp tertile G3; OR = 5.650, 95% CI 1.992–16.025, P = 0.001 in T24 tertile G3; OR = 4.308, 95% CI 1.480–12.542, P = 0.007 in T48 tertile G3 and OR = 6.384, 95% CI 2.201–18.515, P = 0.001 in T72 tertile G3, respectively). Occurrence of recurrent stroke was highest in the RDW tertile G3 (HR = 4.580, 95% CI 2.123–9.883, P < 0.001 in Tp tertile G3; HR = 5.731, 95% CI 2.498–13.151, P = 0.001 in T24 tertile G3; HR = 3.019, 95% CI 1.969–4.059, P = 0.031 in T48 tertile G3; HR = 3.318, 95% CI 1.598–6.890, P = 0.001 in T72 tertile G3, respectively). Mean RDW levels ≥13.60 among AIS patients undergoing thrombolysis was associated with higher risk of HT and recurrent stroke.

D-dimer Level as a Predictor of Recurrent Stroke in Patients With Embolic Stroke of Undetermined Source.

This study aimed to investigate the value of d-dimer levels in predicting recurrent stroke in patients with embolic stroke of undetermined source. We also evaluated the underlying causes of recurrent stroke according to d-dimer levels. A total of 1431 patients with undetermined source were enrolled in this study and divided into quartiles according to their baseline plasma d-dimer levels. The primary outcome measure was the occurrence of recurrent stroke (ischemic or hemorrhagic) in the year following the stroke event. The risk of recurrent stroke increased significantly with the increasing d-dimer quartile (log-rank P=0.001). Patients in the higher d-dimer quartiles had a higher probability of recurrent embolic stroke because of covert atrial fibrillation, hidden malignancy, or undetermined sources. Most recurrent strokes in Q3 and Q4 were embolic but not in Q1 or Q2. Multivariate analysis revealed that patients in Q3 and Q4 had a significantly increased risk of recurrent stroke compared with those in Q1 (hazard ratio, 3.12 [95% CI, 1.07−9.07], P=0.036; hazard ratio, 7.29 [95% CI, 2.59−20.52], P<0.001, respectively; Ptrend<0.001). Binary analyses showed a significant association between a high d-dimer level above normal range and the risk of recurrent stroke (hazard ratio, 2.48 [95% CI, 1.31−4.70], P=0.005). In subgroup analyses, a high d-dimer level was associated with a significantly higher risk of recurrent stroke in men than in women (P=0.039). Our findings suggest that d-dimer levels can be a useful risk assessment biomarker for predicting recurrent stroke, especially embolic ischemic stroke, in patients with undetermined source.

Coagulation factor XII, XI, and VIII activity levels and secondary events after first ischemic stroke

BackgroundThough risk for recurrent vascular events is high following ischemic stroke, little knowledge about risk factors for secondary events post‐stroke exists. ObjectivesCoagulation factors XII, XI, and VIII (FXII, FXI, and FVIII) have been implicated in first thrombotic events, and our aim was to estimate their effects on vascular outcomes within 3 years after first stroke. Patients/MethodsIn the Prospective Cohort with Incident Stroke Berlin (PROSCIS‐B) study, we followed participants aged 18 and older for 3 years after first mild to moderate ischemic stroke event or until occurrence of recurrent stroke, myocardial infarction, or all‐cause mortality. We compared high coagulation factor activity levels to normal and low levels and also analyzed activities as continuous variables. We used Cox proportional hazards models adjusted for age, sex, and cardiovascular risk factors to estimate hazard ratios (HRs) for the combined endpoint. ResultsIn total, 94 events occurred in 576 included participants, resulting in an absolute rate of 6.6 events per 100 person‐years. After confounding adjustment, high FVIII activity showed the strongest relationship with the combined endpoint (HR = 2.05, 95% confidence interval [CI] 1.28–3.29). High FXI activity was also associated with a higher hazard (HR = 1.80, 95% CI 1.09–2.98), though high FXII activity was not (HR = 0.86, 95% CI 0.49–1.51). Continuous analyses yielded similar results. ConclusionsIn our study of mild to moderate ischemic stroke patients, high activity levels of FXI and FVIII but not FXII were associated with worse vascular outcomes in the 3‐year period after first ischemic stroke.

Factor XI, much more than an innocent observer

Factor XI, much more than an innocent observer

Abstract TP514: The Effect of Statin Adherence on Cardiovascular Outcomes After Ischemic Stroke in Statin Benefit Group: A Nested Case-Control Study

Backgrounds: Irrespective of the indication for statin, statin adherence after ischemic stroke was associated with better clinical outcome. We studied the association between statin adherence and recurrent cardiovascular (CV) events among the patients with acute ischemic stroke and statin benefit. Methods: Using Comprehensive Registry Collaboration for Stroke in Korea (CRCS-K), patients with acute ischemic stroke were identified. Statin benefit was defined using the secondary prevention guidelines of American Stroke Association in 2014. The data for statin prescription after discharge were obtained from National Health Insurance Services (NHIS) claim data by matching with CRCS-K. Statin adherence was measured by the medication possession ratio (MPR), which was dichotomized, setting a threshold of MPR (&lt;80%) to identify patients who were nonadherent. A nested case-control design was used to evaluate the occurrence of recurrent stroke, myocardial infarction, and all-cause mortality for 1 year after discharge. Each case was matched to 4 controls by age, sex, initial stroke severity and registry entry time. Adjusted conditional logistic regression models were used to estimate the odds ratio (OR) of CV events. Results: Among 11,768 patients in NHIS-CRCS-K matching database, 5,504 patients were the statin benefit group and prescribed with statin on discharge. Overall MPR for 1 year after discharge was 73.1%. Overall CV events for 1 year were 569, which was more prevalent in low adherence group. (MPR &lt;80%, 18.0% vs. ≥80%, 6.5%, p&lt;0.0001) In nested case-control data set, lower adherence to statin was associated with a higher risk of CV events compared with higher adherence (adjusted OR 1.496 [1.174-1.904]) after adjusting hypertension, diabetes mellitus, atrial fibrillation, history of stroke, history of antiplatelet drug use and discharge modified Rankin Scale score. Statin discontinuation was associated with higher risk compared with adequate statin prescription. (adjusted OR 2.075[1.622-2.655]) Conclusion: Adequate statin adherence in the patients with acute ischemic stroke and statin benefit was significantly associated with recurrent CV events.

Abstract 251: The Association Between Receipt of Healthcare Services and Post-stroke Hypertension Control

Hypertension is a known risk factor for primary as well as recurrent stroke. Improving blood pressure (BP) control has been associated with decreased risk of recurrent stroke. Several factors have been associated with poor BP control among stroke patients such as non-compliance and clinical inertia. We examined the receipt of health care services by patients in the one-year period following discharge for ischemic stroke. This was a retrospective cohort study of patients who were admitted for acute ischemic stroke at a Veterans Affairs hospital during year 2011 and who were discharged with a BP &gt;140/90 mmHg. The following were reviewed: primary care visits; sub-specialty clinic visits; emergency department (ED) visits; hospitalizations; utilization of ancillary care (i.e., telehealth, pharmacy, nutrition services); medications upon discharge; adherence to medications and occurrence of recurrent stroke during the one-year post-discharge period. The cohort included 124 patients with an average age of 66.4 years (± standard deviation of10.3); 123 were male; 62.9% were white; diabetes mellitus was present in 32.5%; and 13.0% had history of coronary artery disease. The average BP at the time of discharge from the index stroke hospitalization was 149.5/82.6 (±11.3/9.8) mmHg. Only 38.7% of patients had an average BP over the one year period of &lt;140/90 mmHg. The average number of primary care visits during this period was 2.8 (±1.6). The overwhelming majority of patients had at least one primary care visit (N=119, 95.9%) however the median time from discharge to the first primary clinic visit was 32 days (IQR 59). Forty four percent of patients were seen as outpatient by neurology, 19.4% by cardiology, 9.7% by nephrology, 5.7% by nutrition, 23.4% by clinical pharmacy, and 9.7% by the telehealth service. BP monitors were issued to or being used by 39.5% patients. Non-adherence was documented in the medical record as an interfering issue in 25.8% of patients. More than two antihypertensive agents were prescribed at discharge in 50.8% patients. During the one-year post-discharge period 29.0% of patients were hospitalized at least once and 24.2% had at least one ED visit. Recurrent stroke occurred in 3.2% of patients. The stroke rate was 4.23% among patients with uncontrolled BP compared with 2.08% among patients with well-controlled BP (p=0.40). This indicates that patients with elevated BP at the time of discharge from an ischemic stroke hospitalization remain with poorly controlled BP in the year post-discharge. Although patients appear to be receiving primary care services, these visits are not successfully achieving BP control. Relative underuse of certain resources for hypertension management such as ancillary services and home BP monitoring is observed.Future intervention studies seeking to improve the hypertension management of post-stroke patients should address these observed gaps in care.

Rivaroxaban in secondary cardiogenic stroke prevention: two-year single-centre experience based on follow-up of 209 patients.

The main goal of treatment in patients with atrial fibrillation is to counteract the effects of embolisation, considering the relatively high risk of cerebral embolic events. An assessment of the efficacy and safety of rivaroxaban in secondary stroke prevention in patients with non-valvular atrial fibrillation (NVAF). The study concerned 209 NVAF patients (male/female: 117/92; mean age 65.3 years [41-85]), who used rivaroxaban as secondary prevention of cardiogenic stroke. The patients were followed up for 24 months: the control visits were performed 12 and 24 months after the onset of the inclusion. The following aspects were analysed: the occurrence of recurrent stroke and/or transient ischaemic attack (TIA) during rivaroxaban treatment, bleeding episodes with their placement and severity assessment, drug tolerance, and evaluation of the patient's medical records including laboratory tests (e.g. creatinine clearance) and concomitant therapy. All patients underwent physical examination as well as neurological assessment. The mean CHA2DS2-VASc in the study group was 4.16, and the mean HAS-BLED value was 3.31. During the follow-up 13 deaths were noted (6.22%), ischaemic stroke was diagnosed in five (2.39%) subjects, and TIA in three (1.43%) patients. Bleeding complications were reported in 25 (11.96%) patients, two of which were classified as major bleedings (0.95%): an intracranial bleeding (1) and a bleeding from the genital tract (1). For patients with NVAF and cerebrovascular events, the use of rivaroxaban in a real-world clinical setting results in a highly efficacious treatment profile and acceptable safety.

Association of improved outcome in acute ischaemic stroke patients with atrial fibrillation who receive early antithrombotic therapy: analysis from VISTA

Ischaemic stroke patients with atrial fibrillation (AF) are at risk of early recurrent stroke (RS). However, antithrombotics commenced at the acute stage may exacerbate haemorrhagic transformation, provoking symptomatic intracerebral haemorrhage (SICH). The relevance of antithrombotics on the patterns and outcome of the cohort was investigated. A non-randomized cohort analysis was conducted using data obtained from VISTA (Virtual International Stroke Trials Archive). The associations of antithrombotics with the modified Rankin Scale (mRS) outcome and the occurrence of RS and SICH (each as a combined end-point of fatal and non-fatal events) at 90 days for post-stroke patients with AF were described. Dichotomized outcomes were also considered as a secondary end-point (i.e. mortality and good outcome measure at 90 days). In all, 1644 patients were identified; 1462 (89%) received antithrombotics, 157 (10%) had RS and 50 (3%) sustained SICH by day 90. Combined antithrombotic therapy (i.e. anticoagulants and antiplatelets), 782 (48%), was associated with favourable outcome on ordinal mRS and a significantly lower risk of RS, SICH and mortality by day 90, compared with the no antithrombotics group. The relative risk of RS and SICH appeared highest in the first 2 days post-stroke before attenuating to become constant over time. The risks and benefits of antithrombotics in recent stroke patients with AF appear to track together. Early introduction of anticoagulants (2-3 days post-stroke), and to a lesser extent antiplatelet agents, was associated with substantially fewer RS events over the following weeks but with no excess risk of SICH. More evidence is required to guide clinicians on this issue.

Abstract T MP104: The Role of Antithrombotics Therapy in Recent Ischaemic Stroke Patients with Atrial Fibrillation: Analysis from VISTA

Background and Purpose: There is uncertainty on the optimal latency after acute ischaemic stroke at which antithrombotic treatment should commence for atrial fibrillation (AF) patients, in order to prevent recurrent stroke (RS) without provoking symptomatic intracranial haemorrhage (SICH). We sought to describe the risk factors and patterns of RS and SICH in a cohort of patients with AF and recent stroke. Methods: We assessed the association of antihrombotic treatment (i.e. anticoagulants and antiplatelets) with the distribution of the modified Rankin Scale (mRS) at day 90, and the occurrence of RS and SICH. We developed statistical models for the prediction of RS and SICH in the first 90 days after stroke, using univariate and multivariate analysis. Results: Data were available for 1,644 patients. Combined antithrombotic therapy with both anticoagulation and antiplatelet (n=782) was associated with more favourable functional outcome across full scale mRS OR=1.785 (95% CI: 1.316, 2.421; P=0.0002), and significantly lower risk of mortality by day 90, SICH by day 90 and RS by day 90: Mortality day 90 OR=0.344 (95% CI: 0.235, 0.502; P&lt;0.0001), SICH day 90 OR=0.18 (95% CI: 0.086, 0.37; P&lt;0.0001) and RS day 90 OR=0.33 (95% CI: 0.21, 0.53; P&lt;0.0001). Patients with ischaemic stroke who had high baseline glucose had a high risk of both RS and SICH events after stroke. Additionally, patients who had increased neurological impairment, previous history of TIA and received no antithrombotic treatment were at increased risk of RS. The relative risk of RS versus SICH appeared constant over time. Conclusions: It seems justified to initiate anticoagulation immediately the patient attains medical and neurological stability, taking into account the potential of haemorrhagic transformation as part of the natural progression in stroke and the increasing risk of recurrent stroke with time if left untreated. Antiplatelet treatment pending introduction of anticoagulation is reasonable.

Lakunäre Infarkte

Lacunar infarcts, small deep infarcts resulting from occlusion of a penetrating artery, account for about a quarter of all ischemic strokes. The view of lacunar infarcts as a benign and rather innocent vascular lesion has been modified during the last years. Although the prognosis is more favourable than other subtypes during the first years, probably due to the small lesion size, in a longer perspective there is an excess risk of death, continual occurrence of recurrent stroke, and development of cognitive dysfunction. The risk of recurrent stroke is similar to most other types of stroke, and patients are at increased risk to develop cognitive decline and dementia. Increasing age, vascular risk factors, and high nocturnal blood pressure have significant prognostic implications for almost all outcomes. Lacunar infarcts and ischemic white-matter disease, the two main types of cerebral small-vessel disease, frequently co-exist and have synergistic effects on prognosis and risk of cognitive decline. Antiplatelet therapy and risk factor modification are the cornerstones in secondary prevention after a lacunar infarct.